Electronically Signing Documents and Orders

If your organization has implemented the eSignature module, you may be able to sign clinical documents electronically through the Commure Pro Inbox on your Apple device if you have been granted access in your user profile. On an Apple device, the Commure Pro Inbox allows providers to sign and, in some cases, edit or attest to clinical documents that can originate from one or more non-Commure Pro source systems, as well as from the Commure Pro NoteWriter and CPOE applications.

• Documents from non-Commure Pro source systems: Instead of logging into the organization’s source system or visiting the medical records department, a provider can access and sign these clinical documents on their device from the Commure Pro Inbox application. The eSignature module locates clinical documents originating in a source system or transcription system. eSignature assigns these documents to the appropriate provider, who can then view, edit, and sign them on their device. Next, the signed documents are sent to your organization’s system of record that validates the signature and accepts edits. And finally, the system of record stores and manages the signed documents. The documents that are available for electronic signature are based on the types of documents in your source system, as well as the document types that your organization has chosen to enable for eSignature. Some examples of the types of documents that a provider might be able to sign electronically include:
  • Reports: textual documents such as Discharge Summaries, Physician Consultation Reports, Patient Progress Notes, Radiology Reports, etc. For some documents, such as Radiology Reports, either the original report, or addendums to the report, may be electronically signed.
  • Scanned Documents: any document that has been electronically scanned as an image file into your system of record. These may include some of the Reports or Orders listed above. MEDITECH® Magic users will also have access to these additional two document types:
  • Orders: orders for items such as laboratory tests, radiological tests, consultations, etc.
  • Attestations: documents used to confirm that the coding performed when a medical record was abstracted is correct.
• Documents from Commure Pro systems: In organizations where teaching physicians (such as attending MDs) are supervising mid-level practitioners (such as residents or physician assistants), a mid-level practitioner might be responsible for initially creating a clinical note or an order, which would then in turn require review, potential edits, and a co-signature from their supervising provider.
  • Documents from Commure Pro NoteWriter: In this workflow, the mid-level provider creates a note in the Commure Pro NoteWriter application, signs the document within that same application, and also specifies the supervising provider who should co-sign it. The Commure Pro system then sends the document to the eSignature application for the supervising provider, who can view, edit/attest to, and co-sign it from the Commure Pro Inbox on their device. The document is sent to your organization’s system of record, which stores and manages the signed documents, when it is initially signed by the mid-level provider, and then again when it is co-signed by the supervising provider.
  • Orders from Commure Pro CPOE: This workflow is available to organizations with a MEDITECH back-end and requires work by Commure Pro’s Integration team in order to implement it. In this workflow, the mid-level provider enters an order in the Commure Pro CPOE application, signs and submits it within that same application, and also specifies the supervising provider who should co-sign it. The order is routed to the appropriate destination, such as the pharmacy, the lab, and so on for processing. The order is also sent to your organization’s back-end order deficiency system, which then forwards it to the Commure Pro eSignature module for the supervising provider and it becomes available in the Commure Pro Inbox on the provider’s device, so that they can co-sign the order. Once signed, a record of the co-signature is then sent back to the order deficiency system. This same workflow is also followed when a mid-level provider modifies, discontinues, holds, or resumes an order. The process for electronically signing clinical documents is nearly identical for Commure Pro on Apple and the Commure Pro web application. The differences that do exist are described in Functional Differences between Mobile and Desktop Platforms.

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Accessing the Commure Pro Inbox

You can access all of the clinical documents requiring your attention from the Commure Pro Inbox. Please note that the Commure Pro Inbox does not support the Zoomed view on Apple devices—we recommend that you set the following in your device’s settings for optimal use:

• Settings > Display & Brightness > View: Standard To access the Commure Pro Inbox, select the Pending button, located in the bottom toolbar. If you have documents that are awaiting your signature or co-signature, the Pending button will have a red badge with a number, as in this example: . This number represents your total number of unfinished items, such as draft notes and unsigned documents.

1. Tap Pending in the bottom toolbar. The Notifications screen is displayed. The Inbox count, listed on the right side of the row, shows the number of draft notes, notes requiring your co-signature, and orders requiring your signature.
   The Inbox count reflects the number of items at the time of the last sync or the last time you accessed the Inbox. The count is updated when either of the following occurs: a manual or automatic sync, or when the Inbox is accessed.
2. Select Inbox from the Notifications screen. The Inbox screen is displayed, showing the last list you were viewing. If this is your first time viewing the Inbox, All lists are displayed. You can now view, sign, edit/attest, or decline documents as necessary.

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Understanding the Inbox Screen

The Inbox screen shows the list of clinical documents that require your attention. By default, clinical documents are listed by date with the most recent item appearing first. The items that are visible are controlled by list that is selected in the List menu. The List menu button displays options for controlling which list(s) you see in the Inbox screen. You can view All of your deficiency items, or filter by type to show only Notes or only Orders items. The Inbox screen is sticky, so your last selection is remembered the next time you the access the Inbox. Each item is listed in its own row. Items that are displayed in bold typeface indicate that they are unviewed, while items in regular typeface indicate that you have viewed them but have not yet taken some type of action. The following columns of information are displayed for each clinical document:

• Exclamation Mark : This icon indicates a critically overdue clinical document or e-mail that requires your immediate attention. This icon appears in the left-most column in the List display area.
• Draft icon: This icon indicates a note that you have saved a draft.

• Select All/Multi-Select : If enabled for your site and for your user, you can select all items in a list or select multiple items individually, when viewing documents of the same type. For example, if the Orders list is selected so that only orders are shown in the Inbox, you can select all of the orders in the list by tapping the Select All at the top of the column.
• Date: This column displays the date and time associated with the clinical document. For orders, this is the date the order was placed, not the service date of the order.
• Patient: This column identifies the patient name associated with this clinical document. The Patient column is displayed on iPad only.
• Description: The description indicates the name of the document. Some documents, such as radiology reports, are associated with one or more orders or exams. In this case, the document description is the name of the first exam associated with the report, such as “ELBOW AP & LATERAL LEFT.” Furthermore, some documents might be addendum to previous reports. If a document is an addendum, the description is preceded by the word “ADDENDUM:” For example, an addendum to the previous report would be listed as: “ADDENDUM: ELBOW AP & LATERAL LEFT.”
• Status: This column displays the status of clinical documents. The Status column is displayed on iPad only. Possible statuses include: Unsigned status: There are three types of documents that use Unsigned status:
  • Documents Created in your Source System- Statuses visible to the Author. The document awaits your signature.
  • Documents Created in Commure Pro NoteWriter that Require Two Signatures- Statuses visible to the Co-Signing Provider. A note that was created in NoteWriter by a mid-level provider awaits your co-signature.

• Orders Created in Commure Pro CPOE that Require Two Signatures- Statuses visible to the Co-Signing Provider. An order that was created in CPOE by a mid-level provider awaits your co-signature.

Edited status: Documents Created in your Source System- Statuses visible to the Author. You have edited the document, but you have not signed it. This can include revisions to the document, including all text added to the document. Resign status: Documents Created in your Source System- Statuses visible to the Author. A submission error occurred when you attempted to sign and/or edit the document, and you should re-sign it. For example, if you entered the wrong PIN or already signed the document, the document indicates a re-sign (failed) status. The failure reason is displayed at the top of the screen. Draft status: There are three types of documents that use Draft status:

• Documents Created in Commure Pro NoteWriter that Require a Single Signature- Statuses visible to the Author. The document awaits your signature.
• Documents Created in Commure Pro NoteWriter that Require Two Signatures- Statuses visible to the Mid-Level Author. You (a mid-level provider) have started a note in NoteWriter, but you have saved it as a draft. From the Inbox, you can tap the Edit/Sign button to open the document in NoteWriter, complete it, and then Sign it there. Once you complete the note and sign it, the document is no longer visible in the Inbox. You can instead view this document in the Clinical Notes module for the specific patient. The document displays a comment that it is awaiting co-signature, along with the name of the co-signing provider to whom you sent it.
• Documents Created in Commure Pro NoteWriter that Require Two Signatures- Statuses visible to the Co-Signing Provider. You (a supervising provider) have started a note in NoteWriter, but you have saved it as a draft. Only your own draft documents (where you are the Author) are shown with the Draft icon. Draft documents created by mid-level providers (that require your co-signature) are not visible to you in the Inbox. Declined status: Documents Created in Commure Pro NoteWriter that Require Two Signatures- Statuses visible to the Mid-Level Author. The co-signing provider declined to co-sign the NoteWriter document, and it was sent back to you with a message to that effect.

• Author: This column displays the name of the provider who created the note. The Author column is displayed on iPad only.
• Refresh button : Tap this button to refresh the Inbox with updated data, if available.

• Search field : You can search the selected list using any of the available data in the Date, Patient, or Description columns (excluding status). Search only applies to the currently selected list. As you type, only rows with matching text are displayed in the list. Search is available on iPad only.

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Sorting the Inbox List

You can change the sort order in which clinical documents are listed in the Inbox.

• Tap a column heading to sort the list based on that item. An arrow appears in the heading that is controlling the sort:. Tap the heading a second time to toggle between ascending and descending order. For example, tapping the Date heading would sort the items in chronological order by date. Tapping the Date heading a second time would sort the list in reverse chronological order.

• To sort the list so that all overdue documents appear at the top, tap the column with an exclamation mark .

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Viewing the Details of Clinical Documents

When a clinical document is selected in the Inbox, the details of the item are displayed. To view the details of a clinical document:

1. Tap the List menu button and select the list you want to view. All shows all of your deficiency items in the List display area.

Notes shows notes or scanned/transcribed documents that require your signature. You can filter even more by selecting the type of notes, including Draft notes or unsigned notes that require your signature or co-signature. Orders shows only unsigned orders that require your signature. The items in the selected list are displayed.

2. Identify the clinical document that you wish to review, and then tap anywhere in that item’s row. The details of that item are displayed.

You may be able to sign, decline, reassign, or edit the document. You can also skip to the next clinical document in the list. Finally, you can auto-scroll through the clinical document in order to see the complete contents at a faster pace or to find a section quickly.

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Auto-Scroll through Clinical Documents

When viewing clinical documents in the Inbox, you can review multi-page clinical documents at an automated pace using the auto-scroll feature. To auto-scroll through a clinical document:

• When a document is opened in the Inbox, tap the Auto-Scroll button to Scroll or Pause at the bottom-right corner of the screen.

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Skipping Documents in a List

While viewing clinical documents in the Details window Inbox, you can quickly work through the clinical documents in your list by skipping from one clinical document to the next. When a document is skipped, it remains in your Inbox without taking any action on the item.

• Tap Skip to jump to the next clinical document in your list.

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Working with Scanned Documents

Scanned documents are a subset of clinical documents, which are image files (such as tiff or jpeg files) that originate in your institution’s source system. Some clinical documents are scanned into and managed by your source system. When these scanned documents require a signature, the source system sends the document to the eSignature module, and they become available in the Inbox. The following sections describe viewing, signing, and other functions you can perform when working with scanned documents.

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Viewing a Scanned Document

You can view scanned documents in the Inbox using a special viewer that enables you to rotate, resize, and page through a document.

1. Tap the List menu button and select Scanned/Transcribed, under Notes. The items in the selected list are displayed.
2. Select the document(s) that you want to view using one of the following methods:
   • To view one item, tap on the document that you want to see. The document opens in the Inbox.
   • To view multiple items, tap the Select checkbox at the beginning of the row for the items you want, or tap the Select All checkbox column heading at the top of the list.

3. From the document viewer’s task bar, you can adjust the document view:

• Tap the Resize buttons to reduce the document, fit the document to the width of the screen, or enlarge the document.
• Tap the Rotate buttons to rotate a scanned document.
• Tap the Paging controls to page through a document, moving from the beginning to the end of a document or from previous to next pages.

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About Signature Blocks

A signature block is a highlighted area that corresponds to a section of the scanned document where a provider is required to review before signing. A scanned document can contain one or more signature blocks that are embedded in the image. The signature block counter, located at the bottom of the document viewer, indicates the number of signature areas requiring review before signing: Each instance of a signature block may require a provider’s attention before the scanned document can be signed. In some cases, a site may enforce that providers scroll to all of their signature blocks before they are able to sign a scanned document. In other cases, Sign All/Multi-Sign functionality may be enabled for the site and for a provider, in which case, scrolling to signature blocks is not required in order for a provider to sign a scanned or transcribed document.

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Signing Clinical Documents

In most cases, clinical documents require a signature from only one provider. In some cases however, a document requires signatures from two or more providers. The method in which this is handled depends on the source of the document:

• Commure Pro NoteWriter: When a document is created in the Commure Pro NoteWriter application, the author signs the document within that same application and is not required to sign it in the eSignature module, and it is not sent to their Inbox on Apple. However, if the document requires a co-signature by a supervising provider, it is sent to the eSignature module and to the Inbox on Apple for the co-signing provider.
• Commure Pro CPOE: When an order is created in the Commure Pro CPOE application, the ordering provider signs the document within that same application and is not required to sign it in the eSignature module or in the Inbox on Apple. However, if the order requires a co-signature by a supervising provider, it can eventually end up in the eSignature module and to the Inbox on Apple for the co-signing provider.
• Non-Commure Pro source system: When a document is created in a non-Commure Pro source system, and it requires more than one signature, it is sent to the eSignature module for all of the providers at the same time and to their Inbox on Apple. Usually, all of the providers sign the document and the signatures are processed in the system of record with no delay. However, there are a couple of scenarios that may require a provider to wait before signing a document, or to sign a document twice:
  • Some source systems have restrictions in place that prevent a provider from editing or signing a document after it has already been edited or signed by another provider (this is often the case in teaching hospitals where reports that are dictated by residents or nurse practitioners must be co-signed by attending providers). For example, let’s say a provider signs and/or edits a document, and the signature and/or edit has not yet been processed in the system of record. When the second provider attempts to sign the original document, they will receive an error message stating that “This document is pending signature by another provider.” In this case, the second provider must wait until the first provider’s signature and/or edit is processed before they can sign and/or make their own edits to the report. If the first provider made changes to the document, the second provider will receive an updated version of the document for their signature.
  • In another scenario, if one provider signs a document, and then the document is edited by a second provider, the first provider may be required to re-sign the document. An updated version of the document is presented to the first provider, so that they can review the changes and then re-sign it. Whether or not a provider must re-sign a document after edits by another provider is based on an administrator setting. See the Commure Pro Administrator help for information on defining user access to eSignature. It does not matter whether a provider is signing, co-signing, or re-signing a document; the steps involved are identical, and are described in the topics referenced below.

Every user who is authorized to electronically sign clinical documents, is able to sign documents on an individual, one-by-one basis. Some users may also be authorized to sign multiple documents at once (either multiple orders, or multiple documents of any type). The ability to sign multiple documents is based an administrator setting. See the Commure Pro Administrator help for information.

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Signing One Document

Individual clinical documents can be signed from the Inbox by following these steps:

1. Tap the List menu button and select the list you want to view. All shows all of your deficiency items in the List display area.

Notes shows notes or scanned/transcribed documents that require your signature. You can filter even more by selecting the type of notes, including Draft notes or unsigned notes that require your signature or co-signature. Orders shows only unsigned orders that require your signature. The items in the selected list are displayed.

2. Identify the clinical document that you wish to review, and then tap anywhere in that item’s row. The details of that item are displayed.
   If you are looking for a specific item, you can sort using the column headings, or you can search the text that the is visible in the current List display area.
3. The button that is available to sign depends on the types of document you have selected:
   • For Drafts, tap Edit/Sign to open the NoteWriter Wizard and tap Sign/Submit.
   • For Co-Sign notes, tap More and then select Sign to sign the selected note.
   • For Scanned/Transcribed notes, tap Sign to sign the selected note. In some cases, multiple signature blocks exist in a document. Steps for signing scanned documents are described in Signing One Scanned Document.
   • For Orders, tap Sign to sign the selected order.
4. You may now be prompted to enter either your PIN or your password from your source system. Your user permissions determine whether:
   • You enter your PIN or password every time you sign a clinical document; or
   • You enter your PIN or password only the first time you sign a clinical document (per web session). Even in this instance, your administrator may set a limit as to the number of minutes of inactivity that are allowed before your PIN or password times out, and you must re-enter it to sign additional documents.
   • You click the Sign button only to automatically sign documents. No PIN or password is required to sign documents. When you sign a document in the Inbox, the next document in the list is opened automatically.

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Signing One Scanned Document

Individual scanned documents can be signed from the Inbox. To sign one scanned document:

1. Tap the List menu button and select Scanned/Transcribed, under Notes. The items in the selected list are displayed.
2. Select the document that you want to view. The document opens in the Inbox.

Signature blocks appear as highlighted boxes on the scanned document. For example:. Each block is located on or near a section of the scanned document that requires your review.

3. To acknowledge that you have reviewed each signature block, do one of the following:
   • For documents with only one signature block, tap Sign.
   • For documents with multiple signature blocks, tap Next Tag to advance from one signature block to the next. Each block is numbered relative to all the blocks in the document. As you advance block by block, each reviewed block is grayed out and the next immediate block is highlighted in yellow. If your user profile has been setup so that you must scroll through all signature blocks to sign a scanned document, then the Sign button is disabled (grayed out) whenever one or more signature blocks have not been reviewed. If you attempt to sign, an alert message (# requires attention) appears in red to the next to the signature block counter. This message indicates the number of blocks that require your attention before signing. When you have advanced through all the signature blocks in the scanned document, the Sign button is enabled and you can tap it.
4. After tapping the Sign button, you may be prompted to enter either your PIN or your password from your source system. Your user permissions determine whether:
   • You enter your PIN or password only the first time you sign a clinical document (per web session). Even in this instance, your administrator may set a limit as to the number of minutes of inactivity that are allowed before your PIN or password times out, and you must re-enter it to sign additional documents; or
   • You enter your PIN or password every time you sign a clinical document; or
   • You only tap the Sign button; you do not need to enter your PIN or Password.

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Signing Multiple Documents

Either multiple orders only, or multiple clinical documents of all types, can be signed at once from the Inbox by following the steps below. This feature is available only if the functionality has been enabled for your site, and for your user profile.

1. Tap the List menu button and select the list you want to view. Notes includes sub-lists for these types of notes requiring your signature: Drafts, Co-Sign, and Scanned/Transcribed. To use multi-select, you must choose one of the sub-lists under Notes.

Orders shows only unsigned orders that require your signature. The items in the selected list are displayed.

2. Select the documents that you want to sign. There are several ways you can do this:
   • To select several non-contiguous documents (for example, a document at the top of the list and one at the bottom): tap the Select checkbox at the beginning of the row for the items you want.
   • To select all types of clinical documents displayed in the Inbox, tap the Select All checkbox column heading at the top of the list.

3. The button that is available to sign depends on the types of documents you have selected:
   • For Drafts, tap Edit/Sign to open the NoteWriter Wizard and tap Sign/Submit.
   • For Co-Sign notes, tap Sign to sign the selected notes.
   • For Scanned/Transcribed notes, tap Edit/Sign to open each document for editing/signing, and then tap Save & Sign. In some cases, multiple signature blocks exist in a document. Steps for signing multiple scanned documents are described in Signing Multiple Scanned Documents.
   • For Orders, tap Sign to sign the selected orders.
4. You may now be required to enter either your PIN or your password from your source system. Your user permissions determine whether:
   • You enter your PIN or password every time you sign a clinical document; or
   • You enter your PIN or password only the first time you sign a clinical document (per web session). Even in this instance, your administrator may set a limit as to the number of minutes of inactivity that are allowed before your PIN or password times out, and you must re-enter it to sign additional documents; or
   • You tap Sign only to automatically sign all the selected clinical documents. No PIN or password is required to sign documents.

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Signing Multiple Scanned Documents

Multiple scanned documents can be signed at once from the Inbox. To sign more than one scanned document:

1. Tap the List menu button and select Scanned/Transcribed, under Notes. The items in the selected list are displayed.
2. Select the documents that you want to view by tapping the Select checkbox at the beginning of the row for the items you want.
   If a document in the list is currently being edited by another user, a Lock icon appears at the beginning of the row and the item will be excluded from the multi-select action.
3. Tap Edit/Sign. The documents open in the Inbox, in the order in which they were selected.

Signature blocks appear as highlighted boxes on the scanned document. For example:. Each block is located on or near a section of the scanned document that requires your review.

4. To acknowledge that you have reviewed each signature block, do one of the following:
   • For documents with only one signature block, tap Sign.
   • For documents with multiple signature blocks, tap Next Tag to advance from one signature block to the next. Each block is numbered relative to all the blocks in the document. As you advance block by block, each reviewed block is grayed out and the next immediate block is highlighted in yellow. If your user profile has been setup so that you must scroll through all signature blocks to sign a scanned document, then the Sign button is disabled (grayed out) whenever one or more signature blocks have not been reviewed. If you attempt to sign, an alert message (# requires attention) appears in red to the next to the signature block counter. This message indicates the number of blocks that require your attention before signing. When you have advanced through all the signature blocks in the scanned document, the Sign button is enabled and you can tap it.
5. After tapping the Sign button, you may be prompted to enter either your PIN or your password from your source system. Your user permissions determine whether:
   • You enter your PIN or password only the first time you sign a clinical document (per web session). Even in this instance, your administrator may set a limit as to the number of minutes of inactivity that are allowed before your PIN or password times out, and you must re-enter it to sign additional documents; or
   • You enter your PIN or password every time you sign a clinical document; or
   • You only tap the Sign button; you do not need to enter your PIN or Password.

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Editing Clinical Documents

You can edit text-based clinical documents from the Inbox on Apple. The method by which the document is edited depends on the type of document:

• Documents from Commure Pro NoteWriter: When you edit/attest a document that was created in the NoteWriter application, the document opens for editing in the NoteWriter Wizard, rather than in the Inbox.
  • If you are editing a draft document that you authored, you can edit the document at will. When you tap Sign/Submit in the NoteWriter Wizard, you have signed the document.
  • If you are editing a document that a mid-level provider authored and sent to you for your co-signature, you may be able to add comments to each section of the note, or only add a single comment in the Co-Signature section, depending on your system’s configuration. When you tap Sign/Submit in the NoteWriter Wizard, you have co-signed the document (with your additions and the attestation statement defined for your note).
• Documents from your source system: The documents are edited directly in the Inbox. Editable sections of a document become available in a edit mode. If the document is an addendum (as indicated by a document description that begins with the word “ADDENDUM”) then only the addendum may be edited. Sections of the report that were included in the original document cannot be changed in an addendum document.

To edit a clinical document that was derived from Commure Pro NoteWriter:

1. Tap the List menu button and select Notes, or one of the sub-lists under Notes.

The items in the selected list are displayed.

2. Select a document using one of the following methods:
   • To edit one item, tap on the document that you want to edit. The document opens in the Inbox.
   • To select multiple items to edit, tap the Select checkbox next to each document you want to edit, or tap the Select All checkbox column heading at the top of the list to select all items.

3. The button that is available to edit depends on the type of document(s) you have selected.
   • For draft notes, tap Edit/Sign.

• For notes requiring co-signature, tap Attest. If more than one item is selected, you may need to tap More to access the Attest button.

The document opens in the NoteWriter Wizard.

4. Make your edits or additional comments as necessary.
5. Once you have finished your edits to the clinical document, tap the Sign/Submit button. The document is signed (if you are the author) or co-signed (if you are the co-signing provider). You are returned to your Inbox.

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To edit a clinical document, or an addendum to a document, that was derived from your source system

1. Tap the List menu button and select Notes, or one of the sub-lists under Notes, or Orders.

The items in the selected list are displayed.

2. Select a document using one of the following methods:
   • To edit one item, tap on the document that you want to edit. The document opens in the Inbox.
   • To select multiple items to edit, tap the Select checkbox next to each document you want to edit, or tap the Select All checkbox column heading at the top of the list to select all items.

3. Tap Edit. If more than one item is selected, you may need to tap More to access the Edit button.

The text becomes editable.

4. Revise content or add text where necessary.
5. Once you have finished your edits to the clinical document or addendum, take any of the following actions:
   • Tap Save to save your edits to the document. The document is maintained in your Inbox and is not submitted to the system of record. If you selected more than one item to edit, the next item displays for editing.
   • Tap Save & Sign to save your edits and sign the document. When signing a document, you may be required to enter your PIN or password at least once per session. If you selected more than one item to edit, the next item displays for editing.
   • Tap Cancel to remove any edits and return the document to its previous state.
   • Tap Back to Inbox to stop editing the selected items and return to the Inbox. Changes you saved are retained; the rest of the items remain unedited.
   • Tap Skip to jump to the next item in the list without saving any changes.

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Declining Clinical Documents

Occasionally, you might receive a document in error or one that has an issue that only Medical Records or another provider can resolve. In such cases, you have the option of declining a clinical document. Clinical documents can be declined from your Commure Pro Inbox on Apple. What happens to the document after you decline it depends on the type of document:

• Documents from Commure Pro NoteWriter that require your co-signature: When you decline to co-sign a document that was assigned to you, the document is removed from your Inbox and it is sent back to the author (the mid-level provider). The document appears in that user’s Inbox (and eSignature module) with a “Declined” status. You also have the option of including a message to the author when you decline the document.
• Orders from your source system, or orders from Commure Pro CPOE that require your co-signature: When you decline to sign or co-sign an order, it is removed from the Inbox. In addition, depending on how your system is configured, an e-mail may be sent automatically to Medical Records to alert them of the declined order, or the order may instead be sent directly back to your organization’s order deficiency system.
• Documents from your source system: When you decline to sign a document assigned to you, the document is removed from the Inbox and an e-mail is sent automatically to Medical Records, alerting them to a declined clinical document.

To decline signing a clinical document:

1. Tap the List menu button and select the list you want to view. Notes shows notes or scanned/transcribed documents that require your signature. You can filter even more by selecting the type of notes, including Draft notes or unsigned notes that require your signature or co-signature.

Orders shows only unsigned orders that require your signature. The items in the selected list are displayed.

2. Select the document(s) that you want to decline using one of the following methods:
   • To decline one item, tap on the document that you want to decline. The document opens in the Inbox.
   • To decline multiple items, tap the Select checkbox at the beginning of the row for the items you want, or tap the Select All checkbox column heading at the top of the list.

3. Tap More and then select Decline.

The Decline screen appears, allowing you to select a reason for declining and to add any additional comments.

4. Scroll through the decline reasons available at the bottom of the screen, or use the arrows to navigate through, and select a reason for declining, such as:
   • Not my patient
   • Re-dictated
   • Signature not required
5. (Optional) Enter any additional remarks in the text field. This field may or may not be available, depending on your system’s configuration.
6. You may be required to enter either your PIN or your password from your source system. If the field is visible, enter your source system PIN or password.
7. Tap the OK button. The clinical document is removed from the Inbox, and:
   • If it was a NoteWriter document requiring your co-signature, it is sent back to the author.
   • If it was an order, either an e-mail is sent to Medical Records or the order is sent back to your organization’s order deficiency system. If it was a document from your source system, an e-mail is automatically sent to Medical Records for further action.

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Reassigning Clinical Documents

The Reassign function is available only for documents that were created in Commure Pro NoteWriter, and that require a co-signature by a supervising provider. Occasionally, a mid-level provider might send a document to the wrong supervisor for a co-signature. If you receive a document for co-signature, but you feel that a different supervising provider should co-sign it, you can reassign it to that provider. When you reassign a document to a different provider, the document is removed from your Inbox it is sent to the other provider’s Inbox (or eSignature module) for their co-signature. To reassign signing a clinical document:

1. Tap the List menu button and select Co-Sign, under Notes. The items in the selected list are displayed.
2. Select the document(s) that you want to reassign using one of the following methods:
   • To reassign one item, tap on the document that you want to reassign. The document opens in the Inbox.
   • To reassign multiple items, tap the Select checkbox at the beginning of the row for the items you want, or tap the Select All checkbox column heading at the top of the list.

3. Tap More and then select Reassign.

The Reassign Note screen appears, allowing you to select a provider from the search field.

4. Search for supervising provider by entering a few characters of their name and then tapping Search. You may only select providers that are allowed to co-sign documents of this type.

5. Tap the OK button. The clinical document is removed from the Inbox, and is sent to the other provider for their co-signature.

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Functional Differences between Mobile and Desktop Platforms

The specific ways in which the Mobile eSignature application differs from the desktop eSignature application are described below.

• In Commure Pro on Apple, clinical documents are accessed through the Inbox on the Pending Notifications screen. In the Commure Pro web application, clinical documents are accessed through the eSig and Commure Pro Mail tab under the Inbox tab. The available items include clinical documents from your source system (reports, attestations, orders, and scanned documents) requiring your review and action. If your organization has implemented the Commure Pro CPOE or NoteWriter co-signature feature, this can also include clinical documents (entered via the Commure Pro NoteWriter application) or orders (entered via the Commure Pro CPOE application) that require your co-signature.
• The Inbox for Commure Pro on Apple does not include any e-mail messages. For users with the ability to send and receive e-mail messages, Commure Pro Mail is only available through the eSig and Commure Pro Mail tab in the Commure Pro web application.
• The ability to search for a specific clinical document using a few letters or keyword is only available on iPad and the Commure Pro web application.
• The columns displayed in the list of clinical documents are limited on iPhone to only Date and Description.
• The following tabs (visible in the Commure Pro web application), are not available in the Inbox in Commure Pro on Apple:Summary, Inbox Search, Processed Search, Outbox, and Send Commure Pro Mail. The first three tabs are typically used only by administrators for reporting and tracking purposes, and are not useful to providers who are signing documents using the Mobile eSignature application. The Outbox and Send Commure Pro Mail tabs are not included because this functionality is limited to the web application.

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Using eSignature on Both Portal and Mobile Platforms

Locks are imposed on any eSignature sessions to prevent against any simultaneous editing of eSignature data in multiple browser sessions (note that this restriction is also imposed on multiple browser sessions open on a single platform). Clinicians are encouraged to make use of both platforms to leverage the flexibility of the eSignature application, but not during the same time.